Apparently, the Aravind Eye Care System (AECS) provides cataract surgeries to 60% of its patients who cannot afford treatment for free, using a sliding price scheme to maintain profitability (p. 51). Aravind Eye Care covers only 5% of cataract surgeries in India (has 5 facilities in 2 states) and does not operate in other nations (Center for Health Market Innovations). The Fred Hollows Foundation does not operate in India.

Thus, scaling the Aravind Eye Care System to other states in India can be a great priority which would not risk the reduction of funds donated to global health in general (since the operations of The Fred Hollows Foundation will be unaffected).

If profitability can be maintained also in other nations, then the system can be purchased by The Fred Hollows Foundation or other investors interested in sight restoration.

The progressive pricing scheme supports the institutionalization of free sight restoration healthcare. Ideally, this should be extrapolated to other treatments as well. The counterargument for this is that 1) it does not matter how the investor gets funds as long as they are effectively donated to restore sight (an argument for Fred Hollows) and that 2) the government should take care of it by taxation (this seems like a more robust institutionalization of free healthcare but it relies on the profitability of the businesses in the nation; the effective treatment availability may be much less progressive than with AECS; and the AECS can always be acquired by the government or enable it to focus on other priorities, such as capacity building as opposed to urgent problem solving).


Am I still wrong in assuming that an investor should speak with the Aravind Eye Care System?

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A comment on some of your recent posts (not an answer to this question): I find your use of bold text for lots of words to be very distracting. I think your posts would be easier to read if you didn't use bold text at all.

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It might be good to send a version of this question to the Fred Hollows Foundation; it seems fairly technical, and I'd guess that very few Forum users will have the requisite knowledge to weigh in on whether the system should be used more widely than it currently is. Having one conversation with someone who works in this sector could be much more informative than even a lot of solo research.

A couple of notes on the question:

  • To what extent does the Fred Hollows Foundation get support from funders in the EA space? Are you aware of any cost-effectiveness analyses that compare FHF to other global health orgs, or other orgs that specifically handle cataract surgery?
    • I haven't heard much about cataract surgery from EA sources in a long time, which makes me think that the simple answer to your question might be "most funders who think in terms of cost-effectiveness just aren't thinking about this area at all"
  • If Aravind has expanded slowly or stopped expanding (I don't know whether this is true), that might indicate problems with their model or the way the organization is managed, such that it might seem unwise to mimic their strategy or invest in them further.

Ok, noted. But then if people just want to skim the post in seconds (especially those who may not be so interested in the first place) do you think maybe headings or infographics would be more appropriate? What would you recommend?

To the Fred Hollows Foundation? Will they not assert that they first do not operate in India and their services are needed where they operate, plus they are not an investing company? This is why funders are a better audience to decide? Especially considering the innovativeness of EAs? Nevertheless noted.

To answer:

Extent of FHF support from EA: FHF is a TLYCS recommended charity. The cost of treating a cataract surgery versus that of training a guide dog for blind people is a commonly cited example in EA. The revenue of FHF was $650m in 2019. I am not finding any funding from Open Philanthropy/Good Ventures but I think in EA Brazil they selected a cataract organization as one of the 3 non-GW ones and in the Philippines they seem to have also tried to find charities that do similar work to GW organizations, and include The Fred Hollows Foundation on their list. Other local effective donation organizations may include FHF. So, I would suggest that people are at least thinking, if not donating. 

Cost-effectiveness analyses: From the TLYCS page, which cites a World Bank and a GiveWell resource, the cost of one surgery is $100 and prevents 1–30 years of blindness and, in addition, 1–30 years of low vision. Based on GW's analysis, the disability weight of blindness is 0.2. IHME cites 0.187 (range 0.124–0.26) for blindness (e. g. row 209 (original resource)) and 0.031 for moderate vision impairment (e. g. row 207). Assuming 15.5 years of blindness and of low vision prevented, that is 15.5*(0.187+0.031)=3.379 DALYs averted per $100. Assuming a life of 70 years, 100/3.379*70=$2,072/statistical life saved. That is competitive with AMF, which cites about $3,500 per statistical life saved but not with e. g. DMI which should avert malaria for $600. This is neglecting that some people may experience negative quality life (below death) so the assumption of full life quality (1.00) does not make sense – if life is saved, then that can be adding suffering (but if blindness is averted, that may reduce suffering).

Why has Aravind not expanded (uncertain): Yes, perhaps the scalability has issues or it is just the limited motivation to expand, also given the possible preference for keeping respect to a founder by not being too competitive, also due to the developing country and personal mission-driven company context. Limited access to credit or low efficiency and professionalism of local financial markets may be another expansion barrier. According to The Fortune at the Bottom of the Pyramid (inspiration for this post), the organization seemed organized regarding training doctors and delegating work to differently skilled personnel to keep costs low. But that is almost 20 years ago, so maybe competitors implemented similar approach or the real cost of providing a free cataract surgery to a patient increased due to a decreasing cost of other treatments.

TLYCS moves relatively little money compared to GiveWell, and cataract surgery rarely comes up on the Forum. That's where my point came from. (Note that my explanation is meant to be a guess at why AECS hasn't gotten much attention, not an argument that it shouldn't get much attention.)

My rough summary of GiveWell's cataract research (as of 2018): it seems cost-competitive with other work, but there's a lot of uncertainty around cost-effectiveness estimates and they've struggled to find orgs that meet their standards for monitoring and evaluation.

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Do you think maybe headings or infographics would be more appropriate?

I don't think infographics are necessary, or even headings in a short post like this. I just think removing most or all of the bold text would help. (There are other things I'd edit to make some sentences more clear, but I don't have time to talk about them — as I recommend below, reading your post out loud might help you see what is or isn't clear.)

Bold text tells us to stop and really focus on something, but if that happens three times in a given sentence, it breaks up how people typically read.  It might help to read your post aloud, but raise your voice for all the bold text and see if the result feels natural.

Oh, that is interesting. I see that TLYCS moves a few million $/year, GW more than a hundred million.

Yes. It is interesting that TLYCS specifies a 10× greater cost-effectiveness than GW estimates in its updated report.

OK, thank you for the tip!